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Communique

Weekly Communique # 36

17 December, 2020

Dear colleagues,

It’s hard to fully comprehend a year like 2020. The pandemic has affected us all and no doubt its impact will continue and reverberate for some time.

In a year full of so much uncertainty it has been a privilege to lead the Taskforce and provide clinicians across Australia with reassurance and best-practice guidance for the treatment of patients with COVID-19.

It has been a long nine months since our first meeting in late March where we set the ambitious goal of weekly living guideline recommendations with 100% member consensus.

The commitment by our 32 Taskforce members to this cross-disciplinary collaborative model and to provide a unified voice has been truly extraordinary.

Equal to this has been the generosity of more than 260 of Australia’s leading clinical and evidence experts who have met weekly to review the latest global evidence and develop or update the recommendations, representing more than 14,000 volunteer hours. A special thank you to our consumer panel whose members have reviewed each of the living recommendations for preferences and values.

This week marks our 36th weekly guidelines update which now incorporates 118 living guideline recommendations, 10 living clinical flowcharts, and covers over 100 clinical questions. The Taskforce website has been viewed more than 270,000 times, with 170,000 individual users from 180 countries around the world. With a 70% Australian, 30% international audience, Australia is leading the way in living guideline development.

Thank you to our funders—Commonwealth Government, Victorian Government, The Ian Potter Foundation, the Walter Cottman Endowment Fund managed by Equity Trustees and the Lord Mayors’ Charitable Foundation—for their swift support at the start of the pandemic.

We also recognise the invaluable contributions of our partners: Australian Commission on Safety and Quality in Health Care, Cochrane, Consumers Health Forum of Australia, Covidence, Hereco, MAGIC, NPS MedicineWise and the School of Public Health and Preventive Medicine, Monash University.

We acknowledge the hard work and dedication of the Taskforce project and evidence team to deliver a world-class product, while juggling the pressures of lockdown, home schooling and working remotely—it’s been a remarkable weekly operation.

The Taskforce will now take a much-needed break and will be back to work on January 18, 2021.

Wishing you a very happy, restful and safe holiday season.

Sharon McGowan (Chair, Steering Committee) and Julian Elliott (Executive Director)

WEEK IN REVIEW

Taskforce recommendations for remdesivir unchanged following detailed analysis of disease severity subgroups

The Taskforce has completed a comprehensive review to assess the credibility of disease severity subgroups used in its recommendations on remdesivir. This was initiated following the World Health Organisation (WHO) decision to make a conditional recommendation against the use of remdesivir in all hospitalised patients, regardless of disease severity (20 November 2020). This differs from the Taskforce conditional recommendation supporting use in hospitalised adults with moderate to severe COVID-19 who do not require ventilation (invasive or non-invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO)).

The review by the Disease-Modifying Treatment and Chemoprophylaxis Panel and Guidelines Leadership Group, with additional input from virologists and immunologists, concludes that there are several factors that contribute to differences in recommendations between WHO and the Taskforce:

  • The Taskforce considers that delineation of subgroups based on disease severity is credible, and that the observed differences in effect on mortality between subgroups is plausible.
  • The Taskforce is more certain that the effect of remdesivir on mortality is closer to the true effect than WHO, as certainty was not downgraded due to risk of bias (certainty for mortality outcomes within the Taskforce is moderate, compared with low certainty within WHO).
  • As the Taskforce develops recommendations specific to the Australian healthcare context, there are fewer resource limitations and barriers to actioning these recommendations than in many countries within the operational sphere of WHO.

A detailed methods brief outlines the steps taken in this review.

Updates to the living guideline

New recommendations published this week cover:

  • Interferon β-1a (inhaled)
  • Peginterferon lambda

Updated recommendations this week include:

  • Remdesivir for adults
  • Remdesivir for pregnant or breastfeeding women
  • Interferon β-1a
  • Human umbilical cord mesenchymal stem cell
  • Sofosbuvir-daclatasvir

Further details about these recommendations are below.

Taskforce summer holiday schedule

All members of the Taskforce project team will take a well-earned break from December 21, 2020 through to January 18, 2021. The Taskforce will continue to monitor the latest global research findings for COVID-19 and will convene relevant panel meetings should new research be published that would warrant an important change in practice for the treatment of COVID-19 within the Australian healthcare setting.

Otherwise regular panel meetings will recommence from January 18 with our next guidelines update scheduled for January 29, 2021.

 

2020 IN REVIEW

 

QUICK STATISTICS

COVID-19 research pipeline

  • 34,829 studies published or registered in Cochrane COVID-19 Study Register, 1,115 added this week
  • 2,262 randomised controlled trials registered (data from Covid-nma site), 62 added this week
  • 2,787 systematic reviews registered in PROSPERO, 61 added this week
  • 147 randomised controlled trials published (data from Covid-nma site), 8 added this week

 

LIVING GUIDELINES

Australian guidelines for the clinical care of people with COVID-19: Version 32.0

NEW RECOMMENDATIONS

  • Interferon β-1a (inhaled)

Do not use inhaled interferon β-1a for the treatment of COVID-19 outside of randomised trials with appropriate ethical approval.

  • Peginterferon lambda

Do not use peginterferon lambda for the treatment of COVID-19 outside of randomised trials with appropriate ethical approval.

UPDATED RECOMMENDATIONS

  • Remdesivir for adults

Updated wording with no change to the strength and direction of the recommendations.

  • Remdesivir for pregnant or breastfeeding women

The conditional against recommendation from the previous versions has been split into two, based on the patient populations. The populations are now defined as:
1) hospitalised with moderate to severe COVID-19 not requiring ventilation (a conditional recommendation for) and;
2: hospitalised with COVID-19 requiring ventilation (a strong recommendation against).

  • Interferon β-1a

Update to text with no change to the evidence (specification of subcutaneous and intravenous route of administration)

  • Human umbilical cord mesenchymal stem cell

Update to evidence base with with no change to the strength and direction of the recommendation.

  • Sofosbuvir-daclatasvir

Update to evidence base with with no change to the strength and direction of the recommendation.

The Taskforce is continually monitoring research to update recommendations weekly as new evidence accumulates.

 

CLINICAL FLOWCHARTS

10 clinical flowcharts have been developed by the Taskforce to cover:

  • Assessment for suspected COVID-19
  • Management of adults with mild COVID-19 UPDATED
  • Management of adults with moderate to severe COVID-19 UPDATED
  • Management of adults with severe to critical COVID-19 UPDATED
  • Respiratory support for adults with severe to critical COVID-19
  • Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment
  • Management of people with COVID-19 who are receiving palliative care
  • Preparedness for CPR during the COVID-19 pandemic
  • CPR for adults with COVID-19 in healthcare settings
  • Basic life support for adults in the community during the pandemic

Changes to flowcharts this week include:

  • ‘Only in research’ medications updated to include inhaled interferon β-1a and peginterferon lambda
  • Updated CDNA guidelines v3.11

 

EVIDENCE UNDER REVIEW

We are currently reviewing evidence to develop recommendations and flowcharts to guide practice in areas including:

  • Baricitinib NEW
  • Sulodexide NEW
  • Zinc NEW
  • Azithromycin
  • Convalescent plasma
  • Favipiravir
  • Hydroxychloroquine
  • Hydroxychloroquine plus azithromycin
  • Immunoglobulin plus methylprednisolone
  • Ivermectin
  • Ivermectin plus doxycycline
  • Care of people with post acute COVID-19

 

NEWS & EVENTS

Cochrane
This week Cochrane has published:

 

NEW TOPICS AND QUESTIONS

It is a core mission of the Taskforce to engage with frontline clinicians to rapidly identify and address priority clinical questions.

Each week we collect suggestions for new clinical questions or topics for consideration by the Taskforce. A document that lists all of the suggested questions, topics and new patient groups that we have received to date is available here.

Please encourage your clinical colleagues to provide their insights via the website.

Topics